Perioperative beta-blockers in noncardiac surgery: Evolution of the evidence

After studies in the 1990s suggested that beta-blockers offer substantial benefits when given before surgery, several national organizations endorsed the perioperative use of these drugs as a best practice in certain patients. However, subsequent research has cast doubt on whether it is appropriate to use these drugs as widely as suggested by those early studies. KEY POINTS Beta-blockers reduce perioperative ischemia, but the benefit may be only in high-risk patients undergoing high-risk surgery. Currently, the best evidence supports their use in two groups: patients undergoing vascular surgery who have known ischemic heart disease or multiple risk factors for it, and patients who are already on beta-blockers. The Perioperative Ischemic Evaluation (POISE) findings suggest that beta-blockers should be used in the immediate preoperative period only with great caution, after ensuring that the patient is clinically stable and without evidence of infection, hypovolemia, anemia, or other conditions that could make heart-rate titration misleading or use of the drug dangerous. When feasible, beta-blockers should be started a month before surgery, titrated to a heart rate of 60 beats per minute, and continued for approximately a month. If the drug is then to be discontinued, it should be tapered slowly.